.· \

Republic of the Philippines PHILIPPINE HEALTH INSURANCE CORPORATION

Citystate Centro llldg., 70<} Shaw llnulevard, Pasig City Healthline .441-7444 www,philhealth.gov .ph:·

PHILHEALTH CIRCULAR No. 0 /1 · ~/!;

c,_,..,..""'""'IL...::tr.;. ........ ,.......,,....,,.~""~''" ,__.., .... _._";0

TO ALL 1,\ffiMBERS OF THE NATIONAL HEALTH INSURANCE ' PROGRAM, ACCREDITED HEALTH CARE PROVIDERS, ALL

PHILHEALTH OFFICES AND ALL OTHERS CONCERNED

SUBJECT OUTPATIENT HIV /AIDS TREATMENT (OHAT) PACKAGE (Phi/Health Circular 19; s 2010) REVISION 1

L RATIONALE

In support of the United Nation's Millennium Developtrieht Goal Number 6 to halt or reverse the incidence of Human Immuno-deficiency Virus (HIV)/ Acqnired' Immune Deficiency Virus (AIDS) by 2015, Phi!Health through Board Resolution No. 1331, series of 2009 has approved the implementation of an outpatient HIV /AIDS treatment package .. 1bis benefit aims to increase the proportion of the population having·access to effective HIV /AIDS treatment and patient education measures. Guidelines for prollider accreditation and benefit delivery are defined i11 Phi/Health CirC11/ar 19, s 2010. To align it with the "All Case Rate Po fig" '!f the Corporation, tbe guidelines '!f the said circular are hcrei!J om ended.

IL SCOPE AND COVERAGE

This issuance co1ltai11s g11ide/inesfor reimbiiTsemmt '![Out-Patient HW/AIDS Treatment (OHAI) Package. This shall app!J to all accredited health care institutions. that are tksig11ated i!J Department '!f Health as HW /AIDS treatment h11bs.

Jtalidzed parts '!f this isSIIa!tce riflect the amendments and additional gaitk/ims '!f the OHAT Package.

III. GENERAL RULES

A. Accreditation of OHAT Providers .------, 1. There shall be no separate accreditation for HIV/AIDS Treatment Hubs as OHAT Package

~ providers, as long as they are PhilHealth ~ccredited health care instit11tions (H.G.s). In cases when there are gaps· in facility accreditation, claims for the said i.iffomd quarter/ s will not be paid.

~ cs- Accreditation '![Has shall be in accordance with Phi/Health Circ11hr 54, s 2012, Prollitkr Engagement thm a: r.LI . • Acmditatio11 a11d Contracting '!f Health Services and s11bseq11mt iss11ances.

i o:::::d~£4. 2. As prescribed· i!J Phi/Health Circn/ar 2, s-2014 (Enhanced Health Care Instit11tion Portal), Has shall have .:::; ... the Ha Portal i11sta/led in their facility. To· ens/Ire co!ifidentiality, the treatment hnb shall have a dedicated

H a Portal 11ser separate from the one used i!J the fadlifY for its generaladmisiions and other Phi/Health claims.

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3. HIV I AIDS treatment hubs are required to create a trust fund f,;r reimbursement of OHAT Package.

4. In lim with Phi/Health Circuidr 31, s. 2013 (All C= Rates Policy No. 1} that professional services must be provided l!J accredited health care professionals, pl!Jsicians in treatment h11bs m«st be Phi/Health accredited starting J an«ary ·1, 2016. Guidelines for accreditation '![ p~sicians are provided in Phi/Health Circttlar 10, s 2014 (Jhe New Accreditation Process for Health Care Pi'oftssionals and Guidelines for Credentialing and Privileging '![Professionals). For initial accreditation, pl!Jsicians shall s11bmit to the nearest Phi/Health Leal Health Insurance Office or Regional Office the following documents: a. Properfy accomplished Provider Dnta Record for professionals; b. S igmd Peiformance Commitment; c. Updated PRC License or its equivalent; d Two (2) pieces'!f1x1 phokJ; e. Pro'!['![ pqyment '![premium contribution; and f. Certificate '![completed residency training or specialty board certificate if applicable.

B. Eligibility Rules for Members and Dependents

As stated in Phi/Health Circular 32, s. 2014 (Clarification iii the application of qualijjing to ensure entitlement kJ ben¢ts), all tl1embers and their q«alified dependents are eligible if their premium contributions are paid for at least three (3) months within the six (6) months prior to the first dl!J '![ availment The qualijjing six months is inclusive '![ the confinement month.

Sponsored, Indigent and Overseas Workers Program members are entitled to the package if the period of treatment falls within the validity periods of their membership as stated in the MDRIPBEF.

C. Availmentof QHAT P~c_!q,ge 1. The Outpatient HIV I AIDS Treatment (OHA'I) Package shall be paid through a case based

payment scheme. Annual reimbursement is set at thirty thousand pesos (Php 30,000.00). Onfy HIVIAIDS cases cot!ftrmed·E!J STD/AIDS Central Cooperative uboratory (SACQ..) or Research Institute for T ropital Medicine (RITM) reqniringtreatment shall be covered by the package. Excluded in this 0 HAT Package are the following: a. Diagnosis of HIV I AIDS with uo laboratory confirmation b. HIV I AID.S cases with no indication for anti-retroviral therapy c.. Management of patients for pulmonary tuberculosis co-infection. d:.Illness (opportunistic infections) secondary to HIV I AIDS tbatrequires hospitalization e. HIV /AIDS cases reqniring confinement are covered under the regular inpatient benefit of

Phi!Health. A separate package for TB-DOTS may be reimbursed in accredited TB-DOTS facilities. A member may avail of both the OHA T and TB-DOTS packages simultaneously. This package shall onfy be a•'aiiedjrom Phi/Health accreditedHG thnt are DOH designated HIV/AIDS T reatm?nt Hubs.

'-----~6. Package shall be based on the Policies and Guidelines on the Use '![ Antiretroviral Therapy among People Living withBuman Immunodificiency Vimr (HIV) and HIV-exposed I '!fonts prescribed E!J the Department'![ Health (DOH). All treatment hubs in accredited facilities are required to follow the guidelines set by the DOH.

J;V. SPECIFIC RULES 1. Covered items under this benefit are drugs and medicines, laboratory examinations based on the

specific treatment gnideline including. Cluster '![ Diffemztiation 4 (CD4) level determination test, viral load

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(if warranted) and test for monitoring of anti-retroviral ('ARV) drugli toxicity and professional fees of providers.

z: The package will be.released in four ( 4} quarterly payments.at Php 7,500 pesos per release payable to the health care institution. The tmdment hub shall on(y file.otle claim for each patient per quarter regardless tif the number tif consultations. However, if there are no. services provided (i.e. no consultation), there will be no pf!Yment for that quarter. For example:

1~ Quarter 2"d Quarter 3"'. Quarter 4m Quarter Covered January 1 to April1 to July 31 to October 1 to Period March31 Tune 30 September 30 December31 Date/s .. Jan.uary4 • April6 .none • November30 consulted to treatment hub • March 30

----·,·~- -.

Payment for. Php 7,500,00 Php 7,500.00 none . Php 7,500.00 the quarter ...

3. The rule tif single period tif confinement shall not app(y to this Package. However, only l claim per quarter may be filed and it is equivalent to Php7 ,500. Any other claim filed within the same quarter will be denied.

4. Each quarterly claim shall be charged one (1) day against the 45-day annual benefit limit or a maximum of 4 days per year

5. Whm a patient transfers from one treatment hub to another, the following rules shall apply: a. A referral letter to. the receiving facility must be accomplished. b. The. accreditedfocili~ that provided the services for the applicable quarter shall file the claim. c. lf patient transfers within the same quarter, the referringfacili~ ·shall file the claim. Claims for subsequent

quarters shall be filed 1!J the second facili~. d If there are no claims filed I!J the reftrringfacili~, claims filed I!J the reftrral focili~ within the applicable quarter

shall be paid

Claims Availment and Processing

1. Only DOH-designated treatment hubs. in accredited facilities may file for reimbursement for the OHAT Package (see Annex 2for the updated lis~.

2.. The consultation date or date when patient. obtained the ARV drugs from the treatme11t hubs duri11g the applicable quarter-shall be considered as the admission date. If there are several consultations for that quarter, the health care provider shall choose a'!Y one of these as date of admission. The discharge date shall be the same as admission date.

3: Claims for the OHAT Package mnst be submitted to Phi!Health within sixty (60) days tifter the discharge date.

4-. Claims with incomplete requirements shall be returned to sender (RTS) for completion. Claims re­filed with incomplete reqrfiremmts shall be denied.

5. The following documents are required for processing of claims: a. Phi!Health Bmefit Eligibili~ Fo17l1 (PBEF) OR other secondary d01;uments required as protif tif eligibility listed

in Pbi!Health Circulars 50, s-2012 and PC 1, s-2013 in cases when PBEF is i10t available. b. Du(y accomplished Phi!Health Claim Fo17l1 1 (CF1); CF1 shal/no longer be required when PBEF conft17J1ed

(as indicated /Jy a· ''Y «S") the patient's e!igibili~. For succeeding claims tif employed members, CF1 without the employer's signature m'!)l be accepted if there is a11

updated Certificate tif Pmmium Contributions issued I!J Pbi!Health L!ca/Health Insurance Offices/Branches attached to the claim.

c. Duly accomplished Phi!Health Claim Form 2. Instructions and example tif which are attached as Annex 2 and Anmx 3 tif this Cirmlar respective(y.

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d Other documents to be submitted-I11itiaL Claim Succeeding Claims

• Photocopy of the following: 1. Photocopy of the health regimen booklet 1. Confirmatory test results by SA CCL or .2. Waiver and consent for release of

RITM confidential information (See Annex 1) 2. Health regimen booklet that re.flects the •!• Include referral letter in cases oftransfer

recent drug regimen 0 Waiver and consent for release of

confidential information (See Annex 1)

6. For previously diagnosed cases. but are filing for the first time, the claimant must still submit all the necessary laboratory test results· together with the other requirements. This will be considered as the initial claim.

7. To ensure patient's rights to confidentiality, all.claims· for the OHAT Package shall be enclosed in a ~ealed envelope, marked· "CONFIDENTIAL" and submitted to the Phi!Health Regional Office.

8. Phi!Health employees who will be direcdy involved in the processing of claims for HN /AIDS shall sign a confidentiality agreement to further ensure patients' right to confidentiality.

9. All claims for OHA T Package shall be evaluated and processed according to Phi/Health rules and gnide!ines on claims processing

10. bz cases when claims were filed i!J:the referring and receiving facility within the specific quarter, only claims from the reftrringfacility shall be paid

11. Phi/Health Out- atient HW/ AIDS Pack e shall use the Packa e Code and'de£ · tion below: Code Description RVU 99246 OUTPATIENT HN /AIDS PACKAGE

12. As stated in Phi/Health Circtdar03, s 2014, (Strengthening the Implementation '!f the No Balance Billing Policy) the No Balance Billing policy shall apply to member category identified i!J the Corporation who were treated in 0 HAT accredited government facilities.

13. The disposition of Phi!Health payment forO HAT shall be:· a. Eighty percent (80%) for the focili(y to be IISed as revolving fund for the delivery of the required

service/ s such as, but not limited to drngs,. supplies, laboratory reagents, equipment (including maintenance), site improvement, and referral fee· and other services necessary for the delivery '!f the required services.

b. Twenty percent (20o/o)for the professivnal fee. that shall be divided among the HN /AIDS Core Team (HACT) and other staff direcdy providing the services composed of, but not limited to the following: doctors, dentists, nurses, medical social workers, cotmse!ors'and medical technologists.

VIL Repealing Clause All other existing issuances and provisiom. tif previous issuanrer inct1nsistent with this circular are heref!y repealed and/ or amended.

IX. ;Annexes 1. Annex 1-Waiver and consent for release of health information 2. Annex 2- List of accredited DOH-designated treatment hubs J. Anmx 3- Instructions on filing np·C!aim Fonn 2 (GF2) 4. Annex 4- S<imPle Claim Fonn 2

Date signed;; __ 0~'-+iwOV.~,/c,a}lu.OoiS''-----

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, . . ,, .. ~~ . .-:-~

'. -····---~-----------~

. '•· ' ~

,-----,-- -·--.--· ... --- ~- 'IC"---------.. ' --~------- .. _1\llil!' ________ ,

ANNEX!

WJ\lVER AND CONSENT FOR·RELEASE OF CONFIDENTIAL PATIENT HEALTH INFORMATION

I.--------...,---------~ wirh Parienr Code No.~----..,­{NA~.riE OF PATIENT!

ofiC'g;d .~gc, ;,nd.prt·~··•Hly ur:derg~ing tml.i-r~::L.rovinll thernpy hereUy

;:.~uthcri:~{·: _____________ .,-:--,--,-,--,-----~N,\M!: Of /\TTEt->DitHi PHYSICIANj

of ____ 1, -·--:c-c:-c:::-:-::-c:-::-=:-=====:-:-:-------(NA!viE OF ACCREDITED IIOSPlT.•;L)

tw rdt~f\SL' th~ following infnrmnlion from my m1~dical records to PhiiHcc.lth:

-, ·---:·::· :;-' .c'Pc:!c.u:c''c:oc:cc.o':.p::_Y_::Oc_f.:_Hc.l\.:_'c.':::cs-'·t_::•_::·e:::s:::u_::lt_.,-__ _:________ ______ ________ ------------·--

_..]- Photocopy tJf n.mfi·,;nl~ltOl)' L~st result "fr~llll fi.ITM/SACCL ---- ------·------···-

',.

[' Clinical Abstract -

:.~ Hcallh !~egum~-;~ Boc;ld~L

___ :c~ ·e-w"e"ts:~Spt·elf~~-...:~-~-:::::·----'""..: __ : ......... --- ·.- ·

The ;1bov1.~ enumertttec informr~tion iS" t.o be rclen!'ed ~tri !:~ly··to the authori7.cd-.repr~sentati:;e of the "Pht!Jppine He~1lth I osunmce• Cor;porauon ( PhitHeallh}fo·r the purpose of bcnefi.ts i:Jvailment. ·

By 'si-gning -'uek:~;\:.- ! rE:t\tle·~: rhiir pri~~-i'i\em ~;r--Phil-1-fe~lih -·-bel1el1ts JOT'· th-e "Otltpati('nt H.JV /AJDS Tre~fme·nt P~~d~iJge~ht:'~n;:uic.on tny beh<.1_lr to thc~afo_rt!mentioned hospital ror services prm.-ided to· me b~-· th.e hO~·pit~l a·nt!·its:st:arr. · . . . · ... - - · . _ '. _ ·. _ · ~: . . ..

i u'ridei·t~l-;.o::- tG rdd;JsC' Phil He~ll,tl·, a.tH.f its empl~yecs :rnm any -and all !:~~)i!itiet, r~ltltiVf! -to ·:the ..

rdease c:~r rhc·-nbovB.-etJum.er~lLed.1nfa.rntariqn.

Name oi·Ptllienl or Pei"son . ;\"cting 011 P(llient's B~half

Signature· D.ilte

____ rteasot·Js.ror Sig:ning.on,l~ati.~nt:s.B.ehrllf;_,_~· ----'-· --·----'--------~---- -~- ---------- ---·--"--:"-----~------------------------- ----~------ ---- _ .. ----.

Nam:c·o-f 1\tt·endirlg·l~h;.•s1ci-H.·n · ·. D-atr..•

.,

,,

Republic of !be Philippines Department of Health

OFFICE OF THE SECRETARY

DEPARTMENT MEMORANDUM: No. 2015 - Ol?ct

May·7;2015

FOR: ALL DIRECI'ORS OF BUREAUS; SERVICES, and REGIONAL OFFICES; MEDICAL CENTER CHJEFS OF DOH-RETAINED HOSPITAJ,.S, DOH-~TTACHED AGENCIES, lllld DOH­DESIGNATED HIV TREATMENT HUBS, and KEY PARTNERS from the LOCAL GOVERNMENT UNITS, PRIVATE SECTOR and NON GOVERNMENT AND COMl\UJNITY-BASED ORGANIZATIONS, and OTHERS CONCERNED:

SUBJECT: Updated· LiSt of DOH-Designated Treatment Hubs and Satellite Treatment Hubs

The Department of Health, through the National AIDS and STI Prevention and Control Program . (NASPCP) under. the Infectious Disease Office (IDO) of the Disease Prevention and Control Bureau. (DPCB), continues to uphold its mandate to ensure universal access ·to antiretroviral fuempy (ART) to all people living with HIV (PLHIV) needing treatment, in line with fue achievement of Universal Health Cilre or Kalusugang Pangkalabatan

Thus, antiretroviral drugs and oilier HIV .services·can already be accessed through the following DOH-Designated Treatment Hubs:

1. Baguio General Hospital.and Medical Center 2. llocos Training and Regional Medical Center 3. Cagayan Valley Medical Center 4. Jose B. Lingad Memorial Regional Hospital 5, James L. Gordon Memorial Hospital

. 6 .. ~lippin~ Ql'n~ Hospital . 7. San Lazaro Hospital ·8. Research. Institute. for. Tropical Medicine 9. · Makati Medillal Center 10. The Medical City 11. Ospital ng Palawan 12. Bicol Regional Training aro\\ Teaching HCispital n Western VisayasMedical Center. :. .

Building l,.Sanr-o Compouod, Ri2B!Avenue, Sta. Cruz,1003 Manila• Tnmi<Line 6SI-7800DiloctLinc: 711-9501 Pax: 743.1829; 743·1786 • URL: htto:/lwww.doh gov.ph· c>nuiil: osec@doh gov ph

- -------.,.--- ---

----------··------~w-·~·~~----*~~0--•--------------------------

. . .. ' .. . ..

14. Corazon Locsin Montelibano Memorial Regional Hospital 15. Vicente Sotto Memorial Medical Center 16. Gov. Celestino-Gallarres·Memorial·Medical·Center 17. Eastern Visayas Regional Medical Center · 18. Southern Philippines Medical Center 19. Northern Mindanao Medical Center 20. Zamboanga City Medical Center 21. Butnan Medica!. Center 22. Caroga Regional Hospital

Likewise, the DOll expanded and decentralize ART services through the establishment of the Satellite Treatment Hubs. These aim to increase access and maximize coverage by bringing the services closer to the. key populations in key geographic areas, thereby ensuring linkage to care and providing printary care services including provision of ART to PLIDV early in the course of the disease. The following are the established Satellite Treatment Hubs:

1. Quezon City K1inika Bernardo 2; Marikina City Health Office 3. Manila Social Hygiene Clfuic 4. Cebu City Social Hygiene Clinic 5. General Santos City District-Hospital 6. Dr. Rafael S. Tumbokon Memorial'Hospital

This is fur your information and for immediate dissemination.

'At . · P.L RETo.GAJUN,MD.MBA-B Secretary of Health

- ~--·------:-·------·----·--------

- o I ,I

' ANNEX 3- INSTRUCTIONS HOW TO ACCOMPLISH CLAIM FORM 2 (CF2) FOR OHAT PACKAGE

·Claim Form 2 shall be accomplished using capital letters and by checking the appropriate boxes. All items should be marked legibly by using ballpen only.

All dates should be filled out in MM-DD.YYYY format.

CF2 Part/Item

Part I

Part II, item 1

Part II, itemT Part II, item3

Part II, item4

Part II, itemS

Part II, item6 Part II, item7

Description

Phi!Health Accreditation Number of :Health Care Institution

Name of :Health Care Institution

Address Name of Patient

Referred by another HQ

Olnfinement period

Date Admitted

Date Discharged

Patient disposition

Type of Accommodation

Admission Diagnosis/ es

Discharge Diagnosis

Diagnosis

Instruction

Write the Phi!Health Accreditation Number, name of HQ and the address on the space provided.

Write the complete name of the patient in this format: Last Name, First Name, Name Extension (if an}Q, Middle Name. Tick yes if referred from another institution and write the name of referring HQ designated as treatment hub.

The consultation date or the date during which the medicines were obtained during the applicable quarter shall be considered as the admission date. The consultation date or the date during which the medicines were obtained during the applicable quarter shall be considered as the discharge date. Check the box "Improved"

Leave the space blank.

Write ''1-IIV I AIDS". .

Wri::e 'Human Immuno-deficiency Virus - Acquired I=Wle : Deficiency Syndrome". · . /

Write the diagnosis of the patient. I

Wtite the appropriate ICD 10 OJde/ s.

1-----~="'--;--------+,W"'ri'te the RVS Olde 99246 corresponding to OHAT Package.

ICD 10 Code/ s

RVS Olde

Date of procedures

Part II, Special consideration: item 8 g For Out-patient HIV/ AIDS

Treatment Pacl<2.ge

Leave the space blank

WRITE the Laboratory Number as listed in the confirmatory l~boratorytest result (e.g. R01-32-5476).

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.·

CF2 ! Description Instruction Part/Item

)-,---Part II, PhilHealth Benefits WRITE the RVS Code 99246 in the line for first case rate, item 9 leave the second case rate blank.

Pan II, Professional Fees Write the accreditation number and the name of the accredited item 10 HCP on the spaces provided.

Affix the signature of the accredited HCP over his/her name then write the date as the space provided.

Part III Certification of Consumption of TICK first box (Phi!Health benefit .is enough to cover HQ Section A Benefits and PF charges) if the patient did not have any out of pocket

expense related to TB ueatment . (such as payment fer I medicine, laboratory and professional· fee).

Write the amount 7,500 in the space provided for Grand Total of the Total Actual Ch~es

Pan ill Consent to Access Patient Print the name of the patient and affix.his/her signature over Section B Recordls the name.

--·- . -. - ... - ·-·-··-- Write the date when th.is was _s.igned.

if the _patient was unable to si~ tick the appropriate boxes. Pan IV Certification of Health Care Print the name of the authorized person to fill out the claim

Institution and his/her designation. Affix his/her signatut~ above the I name.

Th.is person must review and verify all the entries before affixing his/her signature,

Page 2 ofZ

•

'.

L

~ P,~,i,!,~~~ .. !!h Thl~ form 111.1y bt re]lroduced .:11\d I~ NOT FOR SALE

CF2 (CI<'Ihn Forni 2)

rP.vlo;.etl November 2013 I IMPORTANT REMINDERS: Serle~ # '-'---'--'--'---'--L--'-'-'---'--'---'--' PLEASE WRITE HI CAPITAL LETTERS AI'IO CHECK Thl$ farm toqeth« r1ilh ot~r An 111format10n. fl~ld$ god uck

3, Adclress.t

Write the date that corresponds to the day of consultation in the Health Regimen Card as the date of admission and date of discharge

c.DMe~~;~ .. ~~~~:§~::-~~~2~0~0~,1~1~4~1~~::::::::::~::~~~~==~::~.1" 4, P,,tlent Disposition: (select only 1) ~"<~

~a. Improved D t. Expired, DJte; I .S';;;;d'~'J..ao""'...!.-i=~~--LT~bn:'~'l'.,;:l'r~' =~·.,~· ..li'Dbr•:·~· Db~'~":..-+ Write OHAT on the

related procedures with

corresponding RVS code 0 b, Re<OverN 0 f. TraMferr~~f~ 0 c. HcmeJDi!;charQrd Aoalnst HedU:at Advtse

0 d, Absconded ReiY..on/S for referraVtransf r:

5. Type of Accommorlatlom D Plfvate D lion-Private (Ch.!.rlt't'/5-!mcl')

7. DischargeD DlaQI\Osls

. HIV/AIOS

"·-------------

'·

'·-----------

e.lipedal Con~lder.'ltlon~:

1.1 '- 1 necessary): ICO-Ifl Codejs Rela~~ Proe.edure/~ (If mere's .my)

:-~- OHAT PACKAGE •. •. ----------------'--------------~ ______ .. ______ _ ------··---------------

-----··----------------------··-------------------'--------

Ill.

592.:16

Lata-at'ty (ch<!'!k il!>;)fl(able bOx.:.;)

o ... o~'"' o"""' D "" D "'" 0 "'"' 0 L~rt 0 Rlaht 0 Both

D .... D "'"' 0 ""'" 0 "" D ~'"' D "'"' 0 Ltft. 0 Rlaht 0 B!lth

0 Ldt 0 RIQht 0 Both

D '" D "'"' 0 aoth 0 L~tr 0 Rt.::tht D Both

D "'" D "'" D "'"" 0"• O•ohtOeou• 0"" OruohtOBOlh

a. Fell' thl!' lbUonma "~fltlrt i;rotl!dwts. d~t>rt /xlxth.Jr .Jp~$ .Jnd r!numM'dr~ rht- proudun.>fYnio/1 d.Jrt$ {mm-d.1·)Yff). fr,1rchr!/1K>thMIPI~ S<"t oukJe/JJ~t~.S.

§ H•moo•tr>l$ § ..... T""""'"' Ptl1to1VJI Dla~5 E'Nithyth<:rbPj'

!Udi.:lthmpy (UtZA.C) Ch<!ome>the!-'J)V

R.adlo!:htrapy (CC IBALT) Slmpl>!' Dtbr11tnltl\t -----------------

Z·tlen~!lt Pa<k41J~ ~ode: ------

1 , l

d. N.v TS poT) P.J(/.:.ta~ 0 lnttns!Yo! Pll.ut 0 .,,&nttn.lnce f'llo!t~ Write the Laboratory ,_.., Anlm.Jl Sir .. r.r.·k.Joio (ll.'fllt rlli' d.!t~s {mm-dd·ml'J Wlk'n w ft'I/A,WIIIJ ~ (1/l•d.'C.tl~ :•"rll" (IJWfl_l I NiJTt: .. 1111 R .. bltl V.!l't(IJI.• (loR II). "·'"'"' /IJJIIJ/1/Illt/l"l'fllm (Rf(

Number indicated in the (hly 0 ARV UayJA.RV D<~r 1 A.RV RIG Other~ (Speclrvl

.. Fer .V .. l~l!(Jfll C.ut' P.iti..IOt' · 0 Essen!W Nel'lbom Cart 0 Nt\'lbom tre.ll ITIQ creo!nlna 1e~ 0 tle1vbom $1:r~ntna le~t LFor Newlwm Screening, HIV screening result

fl)r Es~eutlal Nl!'wllom Care, (check AP!IIICllble lloxe\) p!~.,~r ,lttJ.-11 ns:; Fflrtr S!Jt;.~r 11..•1

I.

j ........ ""'" ol ,.,.,,,. C:j """" "" , •• ,., El """''"' ot '" "~''"'" R "'" '""''""" D "'"'"" • '"''"'"" I ''"' okm•"'"'"" """" '" ...,.,._,.. V"mn """'"''~' LJ """"""""'of""'"''""" fo ""' ''"''""~ Write the RVS code of

;:~ f/lltWtl<'llr HIV/A!lJS TJ ... t!m~nt P.lt~ Lalloratory Num": RG1-3Z·$476 ) ____ .. .. '), Ph11He.-.1th l!enetlu

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J, Arst cuc;;:~;~· • .;":;94;;2;;o;";;j•,..<------· 1 OHAT as the nrst case

[ rate JC[110 or RVS Cotle: NA

• •

i 10 Profession<'!! Fl!o!'> I ChllriJeS (Use ~d1lltlon.1l Cfl If neCeiosary)•

Acu.eon:.,tio~ llumbo!r 1 11~m., or Accrnflted lieJnh C<u'<' ~of~st:.M: 1 [J.!t~ SIQM\:1 (!ft..\ II~

I ACcr.:dJwt.on llv.: L........L.~. L-..J 0 IICJ co-p.>ron top c/PI\IlHt'dlth 5eno!'flt

Slm.Jturi? 11\'H :>ru-oted J-J.;m.;. D Wltn cc..pav on top of PI!Url~alth eomefr. ' D..l!<-S~:

L.....J......J L.....J......J l"'etltl"o "' ~dl

ACCrt'diC3110n 11".: _L_, --'- L-..J D flo co-p.'li' on top C•f PIIIIHo:Jith Ben.;>flt

S!OC.Jturt 11110:1 PrWlt.;d II~ D \r'Jlth co-p.1y 00 ICip of PhUH<-..llth ~MI•t ' [1..\ti!' Sloned: L-L..J. L...L.J .

rmnlh "' ~·

ACcrtdJ!.'IIior\ llo.: "L...J

0 IICI co.p.;y on top t.J Ph!JHE-a!th Ben~ftt

510'\Jntt~ llvl;i' Prllil.ed U;m.: D With co-pay on ICIJl or Phlll"t.;111lh ~n.:fr. ' CJltt Sionfd: L-L..J • L.......L..J • Write the amount of ·- '" ·~

PART Ill • CERTIFICATION OF CONSUMPTION OF BENEffiS AND CONSEN TO ACCESS PATIEiiT RECORO/S OHAT package if the 1"

NOTe: M~mbet;/Pdtient should sign on~~ after the applkabla c f!Jes have been filled-out Tick box is checked (The A, CERTJFIL"ATION OF CONSUMPTION OF BENEFITS amount is paid in full to ~ PhiiHE.-a!th 1>:-nE-flt I~ o:nouol\ to (0Vi!'f HCI and PF chMQ~.

tlo purcha*5 of diUCI~/m.:didroes, ~uppf~ts. Cll.l~~. !nd co-pay tor ptofes~ f~ by the- 1'!\o?l~/ ''''" facility) Tot!! ,l..nual Chai"!J.:'.:'

lora! H<?~1th can: 1~ ~

Total Prof~~l\:ll ~; /"' -Grand lora! (. 7.500 J 0 The ~~fit of~ rnembo:ri~~nt was ~~~ly con~ pnorw c~.p.l'f fiR ~ beneftt u .. -~· . compl<-t<-ly consumed 6UT wlth

purcha~${.;xpen~f~ for druo.-/m!;dtcln<- ... supph~~. dlliQOOS.tiCS and omtr ...

.\)The- tOtal co-pay for thl!" foiiOI'iina are·

TotaiAttu.al AniOOnl aft<-r AppfiCation oi

C~WJ;J~· DiScount (L<!' .. PE"r501llJ distount Ph!JH<!!alth Ben.:-flt Amwnt after Ph!!H.:-~Ith D<-l:luctlOn

S-M»r CtmH\IP\'Il•

lou! Health care Amount P ln~tltutlon Ft-t~ Ptd by (Chi'ck .JD tfldr ..J~I/1~):.

. J D ~lembi!'r/P.!Itl~nt 0 HMu

0 Uthei'S (I.e., PC!<! '• P&om[5Wt)' not~. i!'tc.)

TotAl Professional Amount ' ko!'~ Pah:l by (C/I('o.'k d/1 rMt rtpp/1~:;): (l"tlr.urrm,rn.t B """"""'"' 0 HMn olnd11M·

I drcrMtt.-d pf(l(i';..""s/tli'Ul$} lttht~ (I.e., PCSIJ, Prom!S~I)' nr.ot~, tiC.)

b) klrch.!lsoe~tExp .. n•e NOT mc:Juded In tile H<-~llh Care In tltuoon Clwae . " . Total CIY.>t of purch.,~/s for druosJmtc~!cne:> and/« medteJI suppUt$ bouqllt b)• OMan~ 0 Tot.\! Amount ' the pabentJmtrnber wlthllltouiD:k- tho!- HQ 6.n1nQ conflntmrot

Toul cv...t of dlac!nCY.OtJCII.,bor&tory ~~~tlon~ p.lld fllf by lhfo pa~nt/~r Orlo)ll~ 0 Tor.;! Amour.t ' do~ Y~tlllrv"out:.ldl!- ~ HCJ durtnQ confin~ment

'NIJTE: T"Mf Area"! CIJdtUI!$ sfhJuM llr' IJJ:>nt on S~tt!mmr ,,( •U~t>t.mt {SMI

B, CONSENT TO ACCESS PATIENT RECORD/ .. t:

I m.rl!-b'f con~~nt ro tho!' o!'XMllr..!llon by Phi!H-!'J!th ol r~ p.ltlfflt'S med!Co!l ~conB for thl!- purpo?. of Y>!'rlf)-mcr tho!- w-raeity of thl$ c!Jlm. 1 h.;oJ"I!'bY hold Ph\Ho!'alth or any or 11~ offtetro, emp!oy~e~ and/or ~pr~..enU.IHt-S frt-<!- from any Md aH habll!~ relo)tlv~ t'l the hereln·mtntioned con$ent which J luwl!" vo!untarlli' .'lnd w!UIMil'f tuven In S9r '!'Chon wtth m';;~ f« ro!tllbur!t-t\lent t~eror~ Phl!rl-!"alth •

.... } tz..u7A \,.,_ :s I ~ J Zarah Jal) alazar _

PART IV· CfRTIFICATIDN 'lF HEALTH CARE INSTITUTIDil

· 1 cl!rtlfy t/IM Sr!I'IICt'!S reudt!te!lwett' tec~Jrd~ iu tile p.Jllent's clldrt .tlld lte.Jftll Cdrt' IMiitlltioll records .md tlldt tile llt'~lulnfCJmtdtfon give II .tn tme ,tl/dco~rt.

---y~~a~£~-<e__ ____ HOSpii6J"ACimiiifStT:Il0r------~~-~ tJ.,te ~~o~~;-6--~ ;-0-.-~ -;-~--;-----~1..\tu~ IIVo!f Pltnti!'d t-:ame of Autt.ortzK lltfl(l.!.! (o.\p.!City / De~IIOI\ I -nJ .... I ~ !"" I ¥i~r I,. 1

HCl Re:Jres~ntanv~

•